Tuesday, December 21, 2010

The Ineffectiveness of Classroom Education for Safe Sex Promotion: A Critique and Alternative Proposal – Becca Selgrade

Critique: Introduction
Traditional campaigns to encourage safe sex practices use education and fact-based lessons to encourage condom use and/or abstinence from sexual activity. This is particularly true for adolescents in the United States, who receive the majority of their sexual education messages in school classrooms. There are few public health campaigns that use commercials or public messaging, and most of those interventions that do exist are targeted at parents (see commercial). Though the topic of sexual activity is controversial at times, it is essential to have an effective safe sex campaign that targets adolescents and will positively change their behavior. The current system of delivery for safe sex interventions is flawed; classroom-based educational information and limited, fact-based curricula are ineffective methods to promote safer sex practices in adolescents.

Classroom Education
The majority of adolescents’ knowledge of sexual health comes from their experiences at school. The classroom is where students will learn most accurate, health-based information regarding sexual practices. Comprehensive sexual health education includes family life instruction, child development, dating issues, interpersonal relationships, decision-making skills, and contraception/condom use education; safe sex and HIV/AIDS play a small role in the overall health education program. Ineffective programs tend to have broad, generalized topics and are less focused on HIV/AIDS risk reduction (1). Additional issues that have been found to plague safe sex education in the classroom are variations in the quality of safe sex education, lessons dominated by basic drug and sex education, and lack of exploration of peer pressure and refusal skills (2). Given the myriad issues that face the effectiveness of safe sex education in the classroom, it is no longer an effective primary means by which to motivate adolescents to practice safe sex.
Focusing specifically on classroom education for safe sex promotion and prevention of the spread of sexually transmitted infections, there are three fundamental flaws with the current system of intervention. As previously stated, the majority of this education is done in schools and/or through fact-based messaging, which belies increased psychological reactance, dependence on outdated behavioral theories, and inattention to the social norms of the targeted group. These three factors create a less than comprehensive and ineffective campaign to promote safer sex in adolescents.

Psychological Reactance
As defined by psychological reactance theory, psychological reactance is a motivational state, occurring in response to a threat to one’s freedom, which manifests in a desire or effort to reestablish the threatened freedom (3). More specifically, when an individual receives a message that causes him to think his freedom is at risk, he reacts directly against that message and its source. Some sources have more specifically defined “psychological resistance,” which always leads to oppositional behavior in response to a threatening message (4), whereas psychological reactance simply creates a negative attitude, which sometimes leads to oppositional behavior. For the purposes of this discussion, we assume both phenomena are equally pervasive and destructive when concerning health behaviors.
When students are subjected to sexual education in schools, the risk of psychological reactance is high. Studies of educational health promotion messages have shown an increase in negative outcomes when controlling language is used (5). The controlling language represents a threat to the individual’s freedom to make his own choice, and psychological reactance is induced, leading to increased negative outcomes. As far as school-based education goes, students are required to take sex education classes, the classes are taught by older teachers, in a didactic, explicit manner, and the content of the class can seem controlling and scary. All of these factors are known to increase psychological reactance. This curriculum and teaching style can make students feel that they are being commanded to act in a certain manner, thus invoking feelings that their freedom is threatened by these classes and the content of them.
Psychological reactance levels are said to increase in accordance with the importance of the particular freedom the individual feels is threatened (3). Because of the importance of sexual freedom in adolescents, classroom commands are highly likely to cause psychological reactance. Telling students that they should not have (unprotected) sex, not have multiple partners, and not be ignorant of sexually transmitted diseases is likely to create the desire to act in a way that opposes these messages. Research has shown that gay men tend to reject safe sex messages and continue dangerous sexual behavior, despite intensified sexual education lessons (6). Major, well-intentioned sex education efforts can backfire, resulting in psychological resistance at either an individual or a group level (7). Adolescents value their sexual freedom and are likely to reject the message and source (the teacher); they will likely want to experiment with the activities opposing what they have been taught.
Additionally, psychological reactance toward health promotion initiatives is often based on a desire to rebel against dominant social values. This is done by exhibiting risky behaviors, which in turn, creates a sense of freedom and protest (8). Reactance to health promotion is also said to come from a rejection of dominant, medically based lessons and the need to understand risky behaviors as they have been described (6). So, classroom education not only creates an environment for psychological reactance against the safe sex message, but the very content and values being taught are likely to elicit psychological reactance and rebellion.

Use of the Health Belief Model
Classroom health education predominantly uses basic, fact-based messaging to educate students about their health (2). Often, classroom curricula and public education efforts about safe sex use fear-based messages to discourage dangerous sexual behavior. This curricula is based on the Health Belief Model; this Model holds that, in deciding to perform a certain health behavior, an individual considers four factors: his perceived susceptibility to the disease/condition that results from that behavior; his perceived severity of the disease/condition that results from that behavior; his perceived benefit from conducting that behavior; and his perceived barriers to conducting that behavior (9-10). This model leads to a tunneled focus on communicating behavior-related risks, often attempting to “scare” people by portraying the frightening consequences or aspects of the behavior. In sex education classes, there is a focus on ensuring the child is made aware of terrible and easily-acquired risks and consequences of unsafe sex and therefore perceives a great benefit to performing safe sex behaviors. However, this model is based on individual decision-making. It presumes that each person fully considers and rationally weighs these four factors each time he/she makes a decision regarding a behavior, which is not always true when it comes to adolescent sexual behavior.
The Health Belief Model ignores the notion that adolescents act differently when they are “in the heat of the moment.” During sexual encounters, individuals think and act differently than they may under normal circumstances; they are not necessarily able to rationally process their decisions at that point in time. In fact, when sexually aroused, individuals are more likely to react less negatively to a deviant behavior (12). Despite the perceptions of sexual behavior they may have formed at school, students may act entirely out of accordance with the desired, safe sexual behavior when the situation presents itself. The Health Belief Model also ignores the notion that individuals, especially adolescents, are influenced by others around them. Students’ behaviors are influenced by their families, peers, and neighborhoods, and this is particularly true when it comes to sexual and other risky behaviors (11). Young adults are often pressured into sexual behavior by significant others or peer groups. A sexual education curriculum based on an individual, rational-thinking model such as the Health Belief Model assumes that the student simply needs the facts to make the right decisions and is ineffective because it ignores real-world, important decision-making factors like group influences and “in-the-moment” thinking.

Lack of Consideration for Social Norms
In order to more effectively encourage students to engage in safe sex practices, sexual education curriculum developers should consider the “weapons of automatic influence” that have the ability to change human behavior (13). Of these “weapons,” the one most applicable, and most lacking, in the classroom setting is liking. Liking is the concept that if the subjects like and relate to the person giving the message and the message itself, they are more likely to respond to the message. This basic concept behind increased influence can be used in a classroom setting; if a teacher makes an effort to relate his messages and behavior to the social norms of the students, the message will be more likely to change their behavior. Currently, teachers do not try to assess the social norms surrounding sex in the adolescent community. The heightened focus on fact and science that is evident in sexual education classrooms fails to engage alternative “world views” about risk, and likely ignores the “world view” of students (7). Additionally, males and females have different perspectives on sexual health, and programs must account for these differences in order to be effective (1). School-based programs should consider students’ needs and norms.
Programs most effective in reducing risky sexual behaviors were found to have a tailoring of behavioral goals, material, and teaching methods to the age, experience, and culture of the students; inclusion of activities that addressed social or media influences on sexual behaviors; and an attention to strengthening group norms against unprotected sex (14). These successful programs clearly considered the world in which the students live and the cultural norms present in that world, which allowed these programs to more easily achieve the desired outcome.
Because of the rigid structure of the sexual education curriculum, students’ needs are not fully understood and the content does not address the real concerns of the students. For instance, the majority of teachers teach only the basic facts of HIV/AIDS (86.6%) and only a small percentage (37.1%) teach about the correct use of condoms (15). Because there is little discussion with the students and little knowledge about what is currently of concern to them, the curriculum suffers. This is an opportunity to have a more discussion-based, participatory, and less didactic curriculum, which also creates a more effective intervention (7, 14, 16-17). A more thoughtful approach to cultural and health needs will lessen the dependence on technically based curricula and allow for a more dynamic and effective program (8). In sum, a more participatory and culturally-sensitive curriculum will be successful in meeting students’ educational needs and will be more effective in reducing unwanted sexual behaviors.

Alternative Campaign: Introduction
Though there are certainly effective aspects of classroom health education, there are some aspects that must be reconsidered, or, at the very least, augmented. The importance of sexual education in schools cannot be denied; it is the primary means of accurate, complete knowledge for some children. However, as far as safe sex interventions go, the classroom provides an inadequate means for creating behavioral change. Because safe sex messages in classrooms create psychological reactance, are based on the Health Belief Model, and fail to consider the social and cultural norms of adolescents, they must be augmented with a widespread media campaign.
Mass media campaigns have been shown to be effective in producing positive changes in health behaviors across large populations (18). As an alternative to the fact-based methods of sexual education in the classroom, a well-designed mass media campaign can more effectively promote safe sex practices to adolescents. The following media campaign, known as the “COVER UP” campaign, is proposed:
COVER UP is a series of commercials, aimed at sexually active adolescents, which aims to increase the group’s use of condoms when engaging in sexual activity. Commercials are proposed to feature the following aspects:
• Commercials will air in the winter months. They will play love-oriented and upbeat songs, such as Say Hey (I Love You) by Michael Franti & Spearhead (click here to play), in the background, while many young couples are pictured dancing closely and provocatively on a dance floor.
• The couples are wearing sweaters, scarves, mittens, etc.; they look “covered up” for winter. The clothes will be casual, yet trendy, and will be in exiting winter colors. Pom pom hats, striped sweaters, scarves, etc. will be worn.
• The people pictured will be in their late teens and early twenties, and couples will be of all types: different races, sizes, and both hetero- and homosexual.
• The music will play prominently throughout the entire commercial, with a strong beat and rhythm. The dancing will be very visually captivating and sensual. The music and dancing are designed to make the viewer want to dance himself.
• At the end of the commercial, with music still playing, four screens will display the following messages, in sequence:
o When you love someone this winter
o Prevent the spread of sexually transmitted infections
• Commercials will also be available on a campaign website, and will be disseminated through YouTube, Facebook, and other social media sites that are heavily utilized by the target demographic.
The campaign commercials are designed to be engaging; the viewer should feel like he wants to get up and dance, and like he could easily be a part of this sensual, youthful, dancing group. The message is designed to be short and simple; it will be a simple and straightforward message advocating safe sex practices.

Reduced Psychological Reactance
The COVER UP campaign reduces the effect of psychological reactance as compared to classroom-based sexual education. The people in the commercial represent a population that is very similar to the adolescents themselves. There will be representation of most races, genders, sexual orientations, and physical sizes. Studies show that when a message comes from a source that is perceived to be similar to the person receiving it, psychological reactance to that message is reduced (19). Additionally, the commercial campaign utilizes popular music and creates a scene in which the target audience can see themselves. These similarities to their daily life reduce the individual’s perceived threat to freedom; he is less likely to have an oppositional attitude toward the message of “COVER UP.”
Also reducing the effect of psychological reactance is that there is no obvious, controlling source from which the message is coming. Seemingly, the commercial is just coming from the target audience’s peers, who are acting just as the target audience might. If there is less evidence of a dominant and controlling source of the message, less psychological reactance is induced.
Finally, the message itself is not overtly controlling. A strong message of “DON’T HAVE SEX” or “YOU WILL GET SICK” would likely produce an oppositional reaction, but the COVER UP campaign is not threatening the audience’s freedom in such a way. The audience is acknowledged as being free to engage in sexual activity via the images of provocative dancing. In this campaign, sex is seen as acceptable. The audience remains in control of their sexual life; they are just given the choice of “covering up” and being safe, like their peers have chosen to do.

Use of Advertising Theory and Public Health Branding
As an alternative to the individualistic Health Belief Model that creates the basis for classroom education, the COVER UP campaign is based largely on Advertising Theory and public health branding. These concepts have more realistic, group-based elements.
Firstly, Advertising Theory is based on the premise that interventions are effective when the audience is given a grand promise that the desired behavior will deliver to them. Regardless of the rationality of this promise and its delivery, effective communication and support of the promise will make the intervention successful and achieve the desired behavior. The most effective campaigns will portray and promise achievement related to the audience’s core values, and will be able to influence large groups of people at once (20). The promise portrayed by the COVER UP campaign is one of sexual freedom. The audience will understand, and actually see, that they will have increased sexual opportunities and increased control over when and how they want to “love.” For adolescents, sexual freedom and maintenance of control are core values; the campaign promises that condom use will deliver these attributes and supports these promises with visual and written messages. Communicating these promises will effectively induce the target audience to use condoms, thereby increasing safe sex behavior in adolescents.
Secondly, public health branding comes into play because the “Cover up” slogan and trendy, youthful image of the commercials are associated with safe sex and condom use. Public health branding is based on the idea that there can be a set of associations, linked to a name, symbol, etc., that can be associated with a public health behavior (21). The importance is in creating the positive associations; these names and symbols are then representative of the public health behavior itself. The brand associations can be widespread among large groups, almost creating a good reputation for that health behavior among the target audience. The words “COVER UP” create a slogan-like association with condom use, which adolescents can then use in real world situations. The visual image of youthful, sensual people looking trendy and cute creates an association with these qualities and safe sex, much like past retail campaigns from the Gap and Old Navy have created a trendy and cool image for their stores. The COVER UP commercials will create effective advertising and branding for increased condom use among adolescents. These more current and group-based models address the shortcomings of the individual and rational thinking-based Health Belief Model.

Consideration of Social Norms
The COVER UP campaign not only considers the social norms of its target audience, but it also utilizes them to further promote its safe sex message. Using these social norms as part of the promotional message will increase liking and improve reception of the message itself. As previously discussed, liking, the concept of a subject being more responsive to a message he relates to, is lacking in classroom education. To adolescents, sexual activity is a social norm; it is evident in their everyday lives and discussed often. To simply ignore this fact and continue to focus on giving them scientific information about the risks of sex is ineffective. Adolescents have a regularity and familiarity with sexual activity that can be used to the advantage of the COVER UP campaign. By using suggestive dancing and insinuating sexual behavior in a way that students are familiar with, and likely using themselves, the campaign’s commercials will have messages to which students can easily relate. In young men and women, hip hop dancing was found to “set the stage” for what happened next in their sexual and emotional encounters (22). Dancing is clearly a powerful vehicle used in the social and sexual encounters of young people. COVER UP acknowledges this norm among adolescents and therefore uses it such that the sexual message becomes more salient to the target audience, thereby increasing its effectiveness.
Further consideration of the target audience’s social norms is found in the method of distribution for the campaign. The campaign will use the internet as a primary vehicle to display the commercials. Adolescents are spending more time on the internet, particularly for social interaction (23). Their usage is continuing to increase at a fast rate (24). Given the high levels of use of social media sites in this target demographic, the campaign is designed to have a strong internet presence, with social media sites as the focal point. The COVER UP campaign incorporates the social norms of its audience in order to create a more effective safe sex message.

The COVER UP campaign will be an effective public health campaign to encourage safe sex practices among adolescents. Largely disseminated in classrooms, safe sex messages have been stifled by their production of psychological reactance, adherence to the Health Belief Model, and ignorance to the social norms of their audience. Rarely has there been a public campaign encouraging safe sex that has been targeted at adolescents and non-fear-based. Here, it is important to note the possibility of public backlash against the COVER UP campaign. Because the community as a whole is not accustomed to interventions that are so honest and direct, it is possible that it will create some controversy. In the past, people have rejected certain safe sex advertisements because of their perceived promotion of sex. However, part of the effectiveness of the campaign lies in its honesty and realistic approach to adolescent sex. Its effectiveness will likely prevail.
The COVER UP campaign will address the shortfalls of classroom based education. By creating a unique and exciting campaign that reduces psychological reactance, uses the social norms of the target audience, and relies on theories meant to influence an entire group, the campaign will be more effective in increasing safe sex practices and attitudes among adolescents.

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